Fillable Ag-501 - Direct Deposit Authorization Form printable pdf download

Ag-501 - Direct Deposit Authorization Form

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AG-501 (11/14/12)

Texas A&M AgriLife

Administrative Services – Human Resources

DIRECT DEPOSIT AUTHORIZATION FORM

Attach voided check for checking account or copy of account number card for savings account.

EMPLOYEE IDENTIFICATION – To be completed by employee

Name:

UIN:

E-mail:

Mail Stop:

Department:

Work

Home

Phone:

FINANCIAL IDENTIFICATION

– Complete this section ONLY if voided check is not attached. To

be completed by employee or financial institution representative if check or copy of account

ACTION

number card is not included.

REQUESTED

Name of Bank/

Phone:

Credit Union:

Initial Set-up

Bank Address:

Change

City, State, ZIP:

Cancel

Electronic deposit routing number

(obtain from bank/credit union):

INDICATE

ACCOUNT TYPE:

Account number:

Checking

Name of person completing this

Section if other than employee:

Savings

Will these payments be forwarded to a financial institution outside the United States?

Yes

EMPLOYEE AUTHORIZATION

I authorize the AgriLife HR/Payroll Office to deposit by electronic transfer my payroll amounts to the financial institution and account indicated

above. I acknowledge responsibility for providing complete and accurate information on this authorization form and understand that the

HR/Payroll Office may contact my financial institution to confirm accuracy of information. I also acknowledge that I will receive an electronic

notification of earnings from the HR/Payroll Office which will be an email confirming that my payroll data is available on HRConnect. I understand

that a paper retainer will not be printed and distributed for me. This authorization is to remain in effect until I provide written notice of cancellation.

The HR/Payroll Office reserves the right to reverse an incorrect posting; however, I fully understand that the HR/Payroll Office must notify me on

or before the settlement date (payday) and explain the reason for reversal. I further understand that it will be my responsibility to contact the

HR/Payroll Office prior to making changes in my account, i.e., closing account, changing banks, etc.

Signature:__________________________________________________

Date:_____________________________________

Return form to the AgriLife HR/Payroll Office via Laserfiche Or mail to: 2147 TAMU, College Station, TX 77843-2147